2022 Camp Healing Hearts Application

2022 Camp Healing Hearts Application

Please note: If you are applying for more than one child, you may add in the information for each child using one application. Please clearly indicate the information for each child in each section of the application. Please fill out ALL information legibly. A complete application and payment is required to register for Camp. Should you have any questions, please call (315) 634-2208.
Camper's Legal Name:

First Name Last Name
Camper's Preferred Name:
Camper's Date of Birth
Month/Day/Year
Camper's Age (at Camp)
Camper's Gender (Optional):
Camper's Ethnicity/Race (Optional):
Grade for School in September 2022:
Camper's School Name:
Camper's Parent(s)/Guardian(s) Full Legal Name(s):
Address of camper: (Please include address of Parent(s)/Guardian(s) if different)
Contact number(s) and type (home,work, cell)
Allowed to leave a message? If YES, please indicate home, work or cell:
Email address:
Authorized to talk to anyone else besides parent/guardian entered? If yes, provide names of those authorized:
Emergency Contacts and Authorized Pick-Ups (Other than Parent(s)/Guardian(s): (include Full Name, Relationship, and Telephone #)
Camper's T-shirt - Please check size as follows:

CHILD Small (6-8) CHILD Medium (10-12) CHILD Large (14-16) ADULT Small ADULT Medium ADULT Large ADULT XL
Has this camper previously attended Camp Healing Hearts in person or virtual? (Indicate YES or NO)
Yes or No
How did you hear about Camp Healing Hearts? (referral source)
(Newsletter, Physician, Media, Friend/Family)
Bereavement History. Please include as many details as possible when answering the following questions. We understand that answering some of these questions might be difficult; however, we want to be able to provide the best possible support for each camper.
Full name of person(s) who died:
Relationship(s) to child:
Birth date and age of person(s) who died:
Date of death(s):
Was the person(s) who died receiving Hospice of CNY and Hospice of the Finger Lakes Services at the time of death?

Yes No
Did this camper received services at The Hospice Grief Center?

Yes No
If the answer to the above is Yes, when?
What were the cause and circumstances of the person's death(s)?
Was there a funeral or memorial service?

Yes No
If YES, did the camper attend, and what were their comments/reactions to the service(s)? Is there anything the child has not been told about the death(s)?
How would you describe the camper's relationship with the person(s) who died:
How does the camper's family communicate about the death(s) and the person(s) who died?

We talk about it often We talk about it sometimes We rarely or never talk about it We avoid talking about it
Comments:
REACTION TO THE DEATH(S): Please explain how camper shows their grief:
Is the camper currently receiving or received any professional support or counseling (i.e. therapist, support group, psychiatrist, or pastoral support)?

Yes No
If Yes, which type of professional support was utilized, and what were/are the circumstances?
Have there been any other changes or stresses in the camper's life (i.e. illness, relocation, divorce, remarriage, finances, other losses)? Please explain.
Please describe the camper's personality/character traits (i.e. easy-going, shy, out-going, takes time to warm up, etc.)
Are there any language, disability, and/or religious needs that we should be aware of to better serve this camper?
Are there any other special needs, family customs, or cultural aspects to the camper's grieving that we should be aware of?
Camper Physical & Health History Form

Camper's Name:__________________________________________________ This form needs to be fully filled out for application to be considered complete.
Section I - HEALTH HISTORY

Has camper experienced/experiences ANY of the following:

Please answer YES or NO below:

	YES	N0
Asthma
Autism Spectrum Disorder (ASD)
Diabetes
Seizures
Meningitis
Fainting
Heart Disease
Intellectual Disability
Wears Glasses
Hearing Impairment
Nosebleeds
Sickle Cell Anemia
Constipation/Diarrhea
Attention Deficit Hyperactivity Disorder (ADHD)
Attention Deficit Disorder (ADD)
Serious Illness or Accident
Other

If you answered YES to any above, please explain further:
Section II - ALLERGIES
Are there any allergies to food, medicine, bee stings or other?

YES NO
IF YES, please specify allergy and precautions taken:
Will an EPI Pen be brought to Camp Healing Hearts? (please check one)

YES NO
Section III - MEDICATIONS
Will medication need to be administered at Camp Healing Hearts?

YES NO
If YES, identify medication and directions for administration. Please include the following information: Medication Name, Dosage, and When Taken
If YES, identify medication and directions for administration. Please include the following information: Medication Name, Dosage, and When Taken
Will an Inhaler be brought to Camp Healing Hearts?

YES NO
If YES, will child be responsible for Inhaler or will it be given to the Camp Nurse? Please check ONE:

Child Camp Nurse
I give the camp staff permission to administer over-the-counter medications available to my child as needed (ie: Tylenol, Ibuprofen, Caladryl, Benadryl, Maalox, etc.)

YES NO
Name of Camper's Physician and Telephone#:
Hospital of Choice:
Camper's Health Insurance & Effective Date:
Camper's Health Insurance Plan Number
Camper's Health Insurance Group Number
To the best of my/our knowledge, the above information is correct and accurate. I/We give permission to agents of Hospice of CNY and Finger Lakes' Camp Healing Hearts to administrator first aid to my camper/child and authorize emergency transport to the nearest acute care facility.
Signature of Parent(s)/Guardian(s)/Date to confirm information is correct and accurate on form and agree to first aid to be administered in case of emergency:

Clear
If bringing Medication, Inhaler, or EPI Pen to Camp Healing Hearts:

I/We authorize and request Hospice of CNY and Finger Lakes' Camp Healing Hearts to administrator the medication(s) prescribed by our physician, and in so doing relieve the camp, its agents, employees or representatives, of any responsibility for ill effects which may result from administering of said prescribed medication as per the phyisician's directions listed above.
SIGNATURE OF PARENT(S)/GUARDIAN(S)/DATE - To request/authorize medication prescribed by our physician to be administered during Camp:

Clear
Release & Camp Application Checklist

Hospice of CNY and Finger Lakes' Camp Healing Hearts Release:

Camper's Name:______________________________

In consideration of the above-named camper being granted permission to attend Hospice of CNY and Finger Lakes' Camp Healing Hearts:

I/We agree to indemnify and hold harmless Hospice of Central New York and Hospice of CNY and Finger Lakes' Camp Healing Hearts for any and all claims, demands, actions and judgments whatsoever of every name and nature, both in law and equity, which my camper/child ever had or now has or may have had against Hospice of CNY and Finger Lakes' Camp Healing Hearts for all personal injuries, either physicial or emotional, known or unknown, and injury to property, real or personal, sustained by my camper's/child's person or property duirng their attendance at Hospice of CNY and Finger Lakes' Camp Healing Hearts, including but not limited to injury caused by or arising from Hospice of CNY and Finger Lakes' Camp Healing Hearts own negligence.

I/We hereby give permission for my camper/child to attend Hospice of CNY and Finger Lakes' Camp Healing Hearts from August 22nd through August 25th, 2022. I understand that the camp's goal is to help facilitate the bereavement process of my child and provide support for them in expressing feelings of grief.

I/We give permission for the camper (my child) to be photographed, videotaped or interviewed during Hospice of CNY and Finger Lakes' Camp Healing Hearts under staff supervision. This material may be used for future publicity of Hospice of CNY and Finger Lakes' Camp Healing Hearts, including the news media.

I/We, the undersigned, have read this release and understand all of its items.
SIGNATURE OF PARENT(S)/GUARDIAN(S)/DATE - to confirm we understand all items and have read this release:

Clear
Completed Application:

First Time Campers:

Spots are limited, so campers are accepted on a first come, first serve basis in order of completed applications received.

The application is considered completed when the application form is filled out completely, consents signed, proof of COVID-19 vaccine per CDC regulations is provided, and registration fee is received.

TO MAKE A PAYMENT WITH A CREDIT CARD, PLEASE SEE THE PAYMENT SECTION BELOW.

Returning Campers:

Camp Healing Hearts wants to give all children a chance to experience its healing power. Due to the limited space, returning campers will be placed on a waiting list, and parents will be notified if there are openings available. Registration fees (checks, money orders, etc.) will not be deposited until this time, and returned, if needed. The waiting list will be managed on a first come, first served basis, therefore, completed applications received sooner will receive a higher spot on the waiting list.
OR, download and print the 2022 Camp Healing Hearts Camper Application form here:
Registration Fee Payment

Indivdual Camper -$35

Family - $60
Please select the payment type below: *

CHECK/MONEY ORDER: Please make checks payable to HOSPICE OF CNY and mail to Hospice of Central New York, Attn: Camp Healing Hearts, 990 Seventh North Street, Liverpool, NY 13088. CREDIT CARD: To make a payment with your credit/debit card, please call 315-634-1100 or go to our website at www.hospicecny.org/help-a-grieving-child-today/ and click on the link to make an online payment. I would like to request a Scholarship
DON'T FORGET TO CLICK SUBMIT BELOW WHEN FINISHED!
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2022 Camp Healing Hearts Application

Bereavement History. Please include as many details as possible when answering the following questions. We understand that answering some of these questions might be difficult; however, we want to be able to provide the best possible support for each camper.

Camper Physical & Health History Form

Registration Fee Payment

Indivdual Camper -$35

Family - $60

DON'T FORGET TO CLICK SUBMIT BELOW WHEN FINISHED!